313 F53 CORNELL UNIVERSITY LIBRARY BULLETIN OF THE COMMITTEE OF ONE HUNDRED ON NATIONAL HEALTH. Being a Paper on The Costs of Tuberculosis in the United States and their Reduction. Read at the International Congress on Tuberculosis, October, 1 908, By IRVING FISHER, PROFESSOR OF POLITICAL ECONOMY, YALE UNIVERSITY. AUGUST, 1909. No. 31. . Published Monthly by the Committee of One Hundred on National Health, Office of the Executive Secretary, 69 Church St., New Haven, Conn. Entered as second-class matter at the post office at New Haven, Conn. E.V. ^7^// Cornell University Library The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924012470567 THE COST OF TUBERCULOSIS IN THE UNITED STATES AND ITS REDUCTION. By Irving Fisher, Professor of Political Economy at Yale University. All students of tuberculosis are agreed that it is a costly disease. Sel- dom, however, are the costs formulated and expressed in definite figures. The object of the present paper is to summarize briefly existing data, to classify and estimate the costs, and to point out the extent to which these costs are being reduced, as well as the most promising methods of securing further reductions. We may classify the costs of tuberculosis as follows: Cost in lives Cost in disability Cost in unhappiness Cost in money These costs are not mutually exclusive, but overlap and are interrelated in many ways. It is, in fact, difficult to treat one without treating all. The chief and most fundamental cost is the cost of life, with which we shall therefore begin. I. Cost in Lives. The mortality from tuberculosis may be expressed in several ways — in terms of (1) the number of deaths; (2) the "crude death-rate"; (3) the "cor- rected death-rate";* (4) the death-rates according to age, sex, occupation, housing, financial competence, and other pertinent conditions; (5) the per- centage of deaths from tuberculosis in relation to deaths from all causes; and (6) the curtailment of the "expectation of life." The crude death-rate from tuberculosis of the lungs in the United States is given in the census reports, the latest figures being those in the volume on "Mortality Statistics, 1906." They relate to the "registration area," or States and cities in which accurate records are kept. In this area the death-rate from tuberculosis of the lungs amounted to 159 per 100,000 of population; the death-rate from tuberculosis in all its forms was 184. The * It is unfortunate that corrected death-rates are not more generally calculated, especially in the United States, where, on account of great variations in the age and sex constitution of the population, they would be especially useful. See the writer's "Mortality Statistics of the United States Census," Publications of the American Economic Association, 1899, 6 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. registration area included about half the population, or 41.0 million out of the total population of 83.9 millions. The rate for the non-registration area probably exceeds very consider- ably the rate for the registration area, because of the fact that the non-regis- tration area contains the major part of the negro population, among whom the death-rate is known to be higher than among the whites, and contains, also, the great health resorts in which so many consumptives die, and for other reasons. On the other hand, the non-registration area is far more rural and less urban than the registration area. Assuming that the urban and rural death-rates known for the registration area may be applied to the non-registration area, we obtain for the whole United States an esti- mated death-rate from tuberculosis of the lungs of 142 per 100,000,* or 119,- 000 deaths for our population of 83.9 millions as estimated for 1906. Since we lack any exact statistics, it seems better, in making estimates, to make them too small; these figures are probably about three-fourths of the truth, and the same ratio of understatement applies to all the calculations later in this paper, such as money costs, which depend on these figures. The results are so appalling that we cannot be too cautious in stating their statistical basis. Tuberculosis of the lungs causes in the registration area 86.5 per cent, of the total deaths from tuberculosis. On the basis of this figure for the entire country, the death-rate from tuberculosis in all its forms is estimated at 164 V er 100,000, or 138,000 deaths per annum for the population of 83.9 millions of 1906. It is interesting to compare the American death-rate with the death- rates in some other countries. NUMBER OP DEATHS FROM TUBERCULOSIS OF THE LUNGS PER 100 000 OF POPULATIONS Australasia , , 76 Belgium 109 England and Wales 114 Italy \ . . us Netherlands 13Q United States 142 Japan ' 145 Jamaica 152 German Empire 183 Norway 197 Ireland 210 Servia . , ! . " ! 332 Austria 336 t The figures for the United States are for 1906, as above calculated; those for Australasia, England and Wales, Netherlands, Jamaica, Ireland, Italy, and Servia are for 1905; those for the German Empire, Belgium, and Norway are for 1904; and those for Austria and Japan, 1903. (See Census, "Mortality Statistics, 1906," p. 50.) * The details of this calculation are as follows: The death-rate in 1906 for the registration cities is given in the Census, "Mortality Statistics, 1906," page 51, as 181.5 per 100,000 for 25.8 millions. Applying this death-rate to the non-registration cities THE COST OF TUBERCULOSIS, AND ITS REDUCTION. — FISHER. 7 We have estimated the deaths from tuberculosis of all kinds in the United States as about 138,000. To realize the magnitude of this figure, we may compare it with the deaths from other well-known and much dreaded dis- eases. It equals (if we may judge by the registration area) the combined deaths from typhoid fever, scarlet fever, smallpox, diphtheria, cancer, dia- betes, appendicitis, and meningitis. The extent of the ravages of tuberculosis may be brought home to us with great force if we compute how many of those now living are doomed to die of it if the present death-rate continues. This can be calculated from the deaths at different ages,* as given in the census, assuming that the dis- tribution of deaths by age will' remain the same. Calculating on this basis, it is found that out of 83,900,000, the total number of people living in the United States in 1906, almost exactly 5,000,000 are doomed to die of tuber- culosis in some form. This number may, let us hope, be materially reduced by the preventive causes now being set in motion. As compared with the total deaths from all causes, the percentage of deaths in the registration area of the United States from tuberculosis of all kinds in 1906 is not given in the census volume, but may really be calculated. It is 11.5 per cent. In other words, one death in nine is due to tuberculosis. The deaths from tuberculosis of the lungs alone amount to 9.9 per cent, of all deaths. For males it is 10.1 per cent, and for females 9.8 per cent. The percentage varies greatly at different ages. Calculating from the number of deaths given in the Census, "Mortality Statistics, 1906," page 354, we find the following as the ratios which the deaths from tuberculosis of the lungs bore to the total deaths of that year: TUBERCULOSIS OP THE LUNGS AS PERCENTAGE OF ALL DEATHS. Age. Under 5. 5 to 9. 10 to 14. [15 to 19. 20 to 29. 1.1% i-i% 3.0% 4.2% 5.4% 15.4% 21.1% 35.8% 29.9% 36.9% which comprise 2.7 millions, we find 4900 deaths. In the same way the rural death- rate in the registration cities is given as 122 per 100,000 for 15.2 millions. If we apply this death-rate to the rural non-registration area, which comprises 40.2 millions, we calculate the number of deaths as 49,000. Adding 4900 and 49,000, we obtain 53,900 as the estimated total number of deaths from tuberculosis of the lungs in the non- registration area. The total population of the non-registration area is 2.7 + 40.2, or 42.9 millions. (The death-rate in the non-registration area is, therefore, estimated at 53,900 + 42.9 millions, or 126 per 100,000.) Adding the total deaths of the regis- tration area, or 65,400, we have the deaths in the country, estimated to be 119,500, which for a population of 83.9 millions gives as the death-rate for the whole country 119,300 -v- 83.9 millions, or 142 per 100,000. * See Census, "Mortality Statistics," pp. 354-356. 8 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. TUBERCULOSIS OF THE LUNGS AS PERCENTAGE OF ALL DEATHS. (Continued.) Age. 30 to 39. 40 to 49. SO to 69. 70 and above. Male 27.4% 26.7% 18.9% 14.8% 8.3% 5.5% 1.9% 1-7% We see that the deaths from tuberculosis reach a maximum, as com- pared with other causes of death, at the age of 20 to 29, being then for males a little less than one-third of all deaths, and for females a little more than one-third. For the entire population, the deaths from tuberculosis of the lungs at the third decade of life are almost exactly one in three. This fact is of great significance in any estimate of the cost of tubercu- losis. We cannot estimate the cost of disease by the number of deaths merely. A death from cholera infantum or from Bright's disease is not as great a loss to a nation as a death from tuberculosis; for the reason that infants and the aged are of less value in a population than those living in the prime of life. Tuberculosis picks its victims at the very period when the value of life is a maximum, after the investment in the education and prep- aration for life of the young is finished, and before the period of declining vitality sets in, when the productivity of the individual has become ex- hausted. If we compute the average age at which male [consumptives die in the United States from the deaths at different ages given in the Census, "Mor- tality Statistics, 1906," it will be found to be 37.6 years, and the correspond- ing average for females is 33.4 years.* At these ages the expectation of life is about 30 years, and if there were no such disease as tuberculosis, it would be, according to the calculations of T. E. Haywardf in England, about a year and a half longer. This figure, 30 years, is approximately the number of years of life cut off by tuberculosis, but the method of computing this lost life time — by taking the expectation of life at the average age of dying consumptives — is not theoretically correct, since it is based on the assump- tion that all consumptives live to the exact age of 37.6 for men and 33.4 years for women, and then die, instead of dying at various ages. In order to calculate correctly the average years of life lost through * Dr. Price ("Study of the Economic Course of Consumption in Wage Earners," Journal of the American Medical Association, April, 1905) has estimated the average age at death of consumptive workers in Maryland whose cases were especially investi- gated as 33J years, that for males being 36.7 and for females 29.8. t The Construction of Life Tables and the Application to a Comparison of the Mortality from Phthisis in England and Wales during the Decennia 1881-90 and 1891-1900. THE COST OP TUBERCULOSIS, AND ITS REDUCTION.— FISHER. tuberculosis, we need to consider separately the number dying at each age. We then get the following table, in which the expectation of life for each age is that calculated by Hayward for England on the supposition that tubercu- losis should be completely eliminated. It assumes that if those dying of tuberculosis had not contracted the disease, they would later die of other diseases at the same rates as other members of the community. Agb. Actual Deaths from Tuberculosis of Lungs in Registration Area of U. S. in 1906. Years Actually Lived bt Consump- tives Before Death. Years of Life Cut Off by Death from Tu- berculosis. Of Which THE Years of Life Before 17* Were: And the Years After 60 Were: Leaving A3 THE Years of Life Between 17* and 60: to 4 / M 1,120 \ F 934 / M 242 \ P 304 / M 292 1 F 775 / M 1,980 \ F 3,070 / M 8,900 \ F 9,448 / M 9,290 \ F 6,775 f M 6,730 \ F 3,585 / M 6,300 \ F 3,408 J M 1,096 \ F 959 2,240 1,868 1,815 2,280 3,650 9,687 34,650 53,725 222,500 236,200 325,150 237,125 302,850 161,325 378,000 204,480 82,200 71,925 63,600 54,732 13,200 17,115 14,600 40,300 90,500 145,825 348,000 387,368 286,000 220,187 154,800 88,550 82,500 48,394 6,795 6,425 16,400 13,739 2,415 2,970 1,400 8,580 8,307 1,952 2,854 2,397 7,384 16,467 29,507 75,783 92,840 82,700 69,466 65,000 39,703 82,500 48,394 6,795 6,425 38,620 5 to 9 32,686 8,833 10 to 14 11,291 10,803 15 to 19 3,8 37 29,049 74,033 20 to 29 116,318 272,217 30 to 39 294,528 203,300 40 to 49 150,721 89,800 50 to 69 48,847 70 and over Total / M 35,950 \ F 29,258 1,353,055 978,615 1,059,995 1,008,896 20,215 20,576 342,174 304,880 697,606 683,440 Average: 37.6 33.4 35.5 29.4 34.5 32.0 .6— .7 .6 4- 9.5 10.4 10.0 19.3 23.4 Both 21.4 From these figures we find that for the 35,950 males who died of tubercu- losis of the lungs in the registration area of the United States in 1906, the ages of whom were known, tuberculosis cut off about 1,060,000 years of life, which is an average of 29.4 years for each individual. This is, therefore, the average expectation of life which male consumptives might have had if pulmonary tuberculosis had not cut their lives short. For females the ex- pectation of life at the time of dying is 34.5 years. For both sexes combined it is 32 years. We have calculated these results on the basis of United States figures 10 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. for deaths from tuberculosis, combined with Hayward's figures for ex- pectation of life in England. We have no good recent life tables in the United States, and none at all calculated, like Hayward's, with tubercu- losis left out. But the prevailing life tables in the two countries have been so similar* that it is practically certain our results are approximately correct. The period of 17$ to 60 years has, in accordance with some previous investigations, been taken as the average working or wage-earning period of life in the United States. Of the 29.4 years of life lost by the average male consumptive, one-half a year (0.6 year) occurs, on the average, before the age of 17$, and 9.5 years after 60, leaving 19.3 years as the average loss of working life, which falls between the limits of 17$ and 60 years. Of the 34.5 years of life lost by the average female consumptive, 0.7 year occurs on the average before the age of 17$ and 10.4 after 60, leaving 23.4 as the average loss of life which falls within the working period, 17$ to 60 years. We see, therefore, that two-thirds of the loss of living years caused by tuberculosis of the lungs comes out of the working period of life. If we spread the total loss of living years, 29.4 years for males and 34.5 for females, over the entire number of deaths from all causes, we find that the average is 3.0 years for men and 3.4 years for women. In other words, had pulmonary tuberculosis been entirely absent, the average duration of human life of all men who died in 1906 would have been 3 years longer, and that of women 3.4 years longer. Of these lost years, 2.0 and 2.3 respect- ively are working years. We may compare these results with Mr. Hayward's figures for England. He finds that had phthisis been entirely absent in 1891-1900, the average duration of life would have been 2.22 years longer for males; and for females, 1.93. Of this loss due to phthisis, the major part is from the working period of life, which Hayward takes as from the age of 15 to 65. Of the 2.22 years lost to men, the part which falls between the ages 15 and 65 is 1.67; of the 1.93 years lost to women, the part which falls between 15 and 65 is 1.46. These figures are not strictly comparable with those we have computed for the United States, since the average age of the "dying" is not identical with the average duration of life. The discrepancy is fully explained in text- books on mortality statistics, but it would not probably affect seriously our present comparison. There is one assumption in the calculations thus far made which ought to be mentioned and amended. This is that had victims of tuberculosis been spared that disease, their subsequent mortality would correspond with the mortality of the rest of mankind. It is likely that their mortality would be greater. I do not mean that those who die of tuberculosis are weaker than * See the writer's "Mortality Statistics of the United States Census," Publications of the American Economic Association, 1899, p. 159. THE COST OF TUBERCULOSIS, AND ITS REDUCTION. — FISHER. 11 those who die of other diseases in general, but simply that those who die at any time of life are presumably weaker than those who pass that time without dying. If the victims of children's diseases were protected from them, their lives would, of course, be greatly prolonged, but their subse- quent mortality would nevertheless be greater than that of other infants. In fact, it is believed by hygienists that the reduction in the deaths of in- fants in the last century has been the cause largely of the increased mortal- ity in advanced years. As evidence illustrating such a result, we may note that in Massachusetts the death-rate in 1895 compared with 1865 showed a reduction for all ages up to 40, but an increase for all ages after 50, while the intervening decennium of life, 40 to 49, showed essentially no change.* The same principle which applies to the prolongation of lives of infants must also apply to the prolongation of lives of consumptives. Consump- tives now fall victims to the disease largely in the decennia 20 to 39, and presumably represent in general weaker physical organizations than the average of those who safely pass this period. Without committing our- selves to any theory of specific susceptibility, we may designate their weak- ness as "tubercular diathesis." Therefore, if tuberculosis could be com- pletely eliminated, the weaker lives now mowed down by it would merely be prolonged somewhat, being terminated by a mortality more rapid than in the ordinary life table for periods beyond 20 to 39. It is, of course, impossible to say exactly what degree of increased mor- tality should be ascribed to the present victims of tuberculosis on the hy- pothesis that there were no such disease. Yet this would be necessary in order to accurately correct the figures which we have computed. Fortu- nately some evidence exists in the statistics of post-discharge mortality from sanatoriums for tuberculosis. Dr. Lawrason Brown and Mr. E. G. Pope, in a very valuable and interesting article, have used the records of 2244 patients treated at the Adirondack Cottage Sanitarium. f By this means they have separated the mortality for those discharged as "apparently cured," those "arrested," and those still with "active tuberculosis," and have compared the mortality of each with that of the general population, as indicated by Farr's English life table, No. 3. The general conclusions of this study are that the mortality among the " apparently cured" is at first about twice, and later about three times, the general population, but is considerably reduced after 8 or 10 years. The "arrested" patients have a death-rate rising in the third year to about ten times the general death- rate, and then falling steadily. The patients with "active tuberculosis" * See Abbott, "Vital Statistics of Massachusetts," 1856-95, p. 755, in Mass. State Board of Health Reports, 1896. t "The Ultimate Test of the Sanatorium Treatment of Pulmonary Tuberculosis and its application to the results obtained at the Adirondack Cottage Sanitarium," Zeitschrift fur Tuberkulose, 1908, pp. 206-215. 12 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. have a death-rate at first of about forty times that of the general population, but decreasing rapidly. For our purposes, the most important figure is that expressing the general average death-rate among the "apparently cured," as compared with the mortality of the general population. Their experience furnishes the nearest approach to mortality among those with tubercular diathesis but free from tuberculosis. Unfortunately, they are not really free, however, as most of them later die of the disease. On the basis of the diagram on page 211 of the article above referred to, the "ap- parently cured" die on the average 2.3 times as fast as the general popula- tion during the first 10 years. After 10 years the imperfectly cured seem to be weeded out and the death-rate decreases materially, but the data after 10 years are too meager to enable us to make exact estimates. We may be sure, however, from the form of the mortality curves from the three classes of discharged patients — each of which falls after a weeding-out process — and from other indications that the average mortality of the "apparently cured," if statistics were long enough extended, would be found less than double that of the general population, and that the average duration of life after discharge is greater than half the average duration of life (32 years for both sexes combined) among the general population of corresponding age. In fact, taking the survivorship curve for the "apparently cured,"* which extends 19 years, we find that even if the further end were bent downward for the last 9 years of the 19, so as to correspond to a heavier mortality than the meager data for these 9 years indicate, the average duration of life could not, under any reasonable formula for continuing the curve, be less than 16 years, and might be as much as 20 or even 25 years. At the worst, therefore, the mortality among "apparently cured" consumptives is such as to make their lives 16 instead of 32 years, or, on the average, 16 years shorter than those of the rest of the population. It is not to be inferred, however, that these persons would have had so excessive a mortality if they had never con- tracted tuberculosis. Their curtailment of life is not principally due to inherent weakness of constitution, but to tubercular relapses. Three- fourths of the deaths among the "apparently cured" are from returning tuberculosis. We feel, therefore, safe in saying that the curtailment of life due to weakness of constitution, "tubercular diathesis," cannot be more than half of the total curtailment of 16 years. In other words, if tubercu- losis were non-existent, the expectation of life of those who fall its victims would be at least 24 years, as compared with the ordinary expectation of 32 years among persons who never have tuberculosis. The eradication of tuberculosis would, therefore, save on an average at least 24 years for each person who now falls victim. This is making what appears to be a very generous allowance for the fact that the lives saved are weak. We conclude * Ibid., p. 209. THE COST OF TUBERCULOSIS, AND ITS REDUCTION. FISHER. 13 that the annual life cost from tuberculosis in the United States is, therefore, about 138,000 lives shortened, on the average, at least 24 years each. We may now apply our correction for constitutional weakness or tuber- cular diathesis to the calculation of the loss of working years. We found that, without such correction, the 32 years of life supposed to be cut off for each consumptive were made up of 0.6 year before the age of 17£, 10 years after the age of 60, and 21.4 years between these ages. Carrying out the previous calculations corrected on the new basis, we find that of the mini- mum of 24 years cut off, the parts constituent are $ a year before the age of 17£, 6£ years after the age of 60, and 17 years between 17J and 60. The working period lost by death is, therefore, at least 17 years for each dying consumptive. II. Cost in Disability. Turning from the cost in lives to the cost in invalidism or disability, we find the best figures in the intensive "Study of the Economic Course of Con- sumption in Wage-earners,"* by Dr. Marshall L. Price, of Baltimore, now secretary of the Maryland State Board of Health. This paper shows that deaths among several hundred workmen in Maryland were preceded by an average period of 1 year and 6 months of total disability, following a pre- vious period of 1 year and 7 months of partial disability, during which the workman was able to earn about half wages. Mr. Christopher Eastonf constructed statistics to cover 100 cases in New York city from the. tuberculosis infirmary on Blackwell's Island, in which he found the "average duration of the disease before a patient's admission was 7 months and 21 days; the average period of unsteady employment 3J years. The latter figure is much larger than it would otherwise be by reason of the large number who had been unsteady workers owing to dissipa- tion or some other cause than consumption. The duration of the disease above given, prior to admission, is, on the other hand, probably too short. Many patients have not realized their condition in the early stages of the disease. The corresponding period of the patients admitted to the State Sanatorium, Rutland, Mass., is stated as 12J months, although they receive a more incipient class of patients than the Blackwell's Island Infirmary." We shall take as the period of total or partial disability for the workmen the figures of Dr. Price,! viz., three years and one month. But for consump- tives in general this average should be considerably increased. The period of disability for the well-to-do is undoubtedly in general greater than for workingmen, chiefly for the reason that the workman is * Journal of the American Medical Association, April, 1905. t "Consumption and Civilization," by Dr. John B. Huber, Philadelphia (J. B. Lippincott Co.), 1906, p. 121. t "Study of the Economic Course of Consumption in Wage-earners," by Dr. Marshall L. Price, Journal of the American Medical Association, April, 1905. 14 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. forced to exert all the working capacity he has up to the latest possible moment, after which the course of his disease is apt to be more rapid than that of his well-to-do brother, who is more likely to stop from work in time to secure recovery. So far as I know, however, there are no exact figures to show the period of total or partial disability for the well-to-do. It is probable that death is usually preceded by a period of from 3 to 5 years during which little or no work is done. It seems safe to say that 4 years— certainly Z\ — is not an excessive esti- mate for the infectious period preceding the death of consumptives. If we multiply this figure by the number of deaths per annum from tuber- culosis in the United States (138,000), we shall have a figure, 480,000 to 552,000, which expresses approximately the average number of persons con- stantly suffering from active tuberculosis in the United States and infecting others. In other words, there are always about half a million consumptives in our country, without counting "latent" cases. Since, as Dr. Price has shown, for the working class the period of partial disability is about equal to the period of total disability, and since the working class constitutes the great bulk of consumptives, we may conclude that of the 500,000 consumptives always existing about half are totally and the other half partially disabled. The estimate of 500,000 consumptives is believed to be a very safe one. Osier estimated that there are at least a million and a quarter of cases in the United States all the time, and even this figure is regarded by Dr. Huber as very conservative. It seems, how- ever, much too high, for it would require an average period of tubercular activity of nine years. Dr. Price estimates that "in the State of Maryland at the present time there are 10,000 consumptives,* 8000 of whom have ceased to be economic factors in their communities. The State may have to provide for the sup- port ultimately of these 8000 people who are not economic factors and the majority of whom have no likelihood of ever becoming such, a number larger and more expensive in proportion than the German army, and who, far from procuring and guaranteeing the safety and integrity of the State, are a source of danger or an actual menace to those about them." In treating the subject of disability it must not be forgotten that, in addition to those who are conscious of having tuberculosis, there is a larger number who, without knowing it, suffer some disability from latent tuber- culosis. Nageli has found that 97 per cent, of adults who die of other diseases than tuberculosis are somewhat tubercular. Other investigators have con- * On this basis, according to population, the number in the United States would be about 750,000. THE COST OF TUBERCULOSIS, AND ITS REDUCTION. — FISHER. 15 firmed the conclusion that over 90 per cent, are affected. In other words, most people who grow up have mild tuberculosis without knowing it. They may have suffered from what they believed to be prolonged "colds," "bron- chitis," or " malaria," and recovered without ever having suspected that they had tuberculosis. Any such periods of disability are really costs of tubercu- losis. An interesting case has recently come to the attention of the writer. A lady over 75 years of age was suffering from a "severe cold" and was advised by a friend to have her sputum examined. Much to her astonish- ment, the germs of tuberculosis were found. Shortly thereafter, however, her cough cleared up and her sputum disappeared. Many of her relatives had died of tuberculosis. She had been associated with them since child- hood. Some 50 years ago she is said to have spit blood. It is probable that this woman had unconsciously been fighting tuberculosis for half a century, during which time she was usually feeling very well. Of course, there are no means of estimating accurately the disabilities thus suffered from latent tuberculosis. In the aggregate, owing to the great number of such cases which we know must exist and the number of years they live, it seems not unlikely that the total disability from this cause will equal the disabilities known to be suffered by those subject to active tuber- culosis. That this should be the case would require only an average disabil- ity among latent cases of 3 to 4 days a year. Dr. Barnes in an interesting paper has shown that there are a great many cases in which delay in diagnosis occurs.* The experience of all who have visited Saranac Lake, Colorado Springs, or Santa Barbara and similar resorts will corroborate these results. Nothing has yet been said in regard to the disability, or indeed, mortal- ity, of cured cases of tuberculosis. It must be admitted that the number of such cases is as yet insignificant compared with the total number of deaths. It is only the lucky few in whom tuberculosis is discovered early enough in the incipient stage. Among the really incipient and "curable" cases, about one-third die after a more or less prolonged period of disability; one-third have the disease arrested during a period of partial disability lasting a number of years. * Of 165 cases there were 89 cases, or 54 per cent., correctly diagnosed; 76 cases, or 46 per cent., incorrectly diagnosed. Of the 76 cases, the resulting delay in correct diagnosis was: Two to six months in 41 cases Six to twelve months in 15 cases Over twelve months in 20 cases The longest delay was 120 months The shortest delay was 2 months The average delay was 11.3 months (From "Mistakes in the Diagnosis of Pulmonary Tuberculosis," by Harry Lee Barnes, M.D., The Journal of the American Medical Association, Feb. 16, 1907, vol. xlviii, pp. 601-605.) 16 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. Of the remaining third which is "apparently cured," a large number relapse later, and few have their original working capacity restored for a normal period of after life. Taking the statistics of Brown and Pope already referred to, we find that they indicate an average life after discharge for those who still had " active tuberculosis" of about 4 years; for those with the disease "arrested," about 10 years; and for those who were "apparently cured," about 16 to 20 years. The last-named figure is the least certain, owing to the fact that, when the statistics were compiled, the number of persons who had been discharged from the sanatorium over 10 years was too small to [furnish a very adequate basis on which to compute the after-age. For these three classes there are no exact figures for working capacity. It is a reasonable hypothesis that those with "active tuberculosis" have a working capacity which is almost negligible, and the "arrested" and "ap- parently cured" have recovered respectively about one-half and three- quarters of their normal capacity. III. Cost in Unhappiness. In addition to the costs thus far considered, there is the cost which cannot be calculated, in disappointment and unhappiness on the part, not only of the consumptive himself, but of his family and friends. It would be idle to attempt to estimate this "misery cost" of tuberculosis, and still more idle to attempt to express it in money. Suffice it to say that, on the average, each consumptive places upon three or four other members of the com- munity the burdens of his prolonged illness and death. There must always be between one and two million people in the United States upon whom the dark shadow of this scourge rests, and double this number, if we include those who mourn the loss of their loved ones. IV. Cost in Money. We come, finally, to the cost of tuberculosis in money. This cost con- sists of actual money expenditures and of loss of earnings. The actual money cost occasioned to the patient and his family by tuberculosis con- sists of expenditures for physicians, medicines, nursing, traveling, and usually — alas! — burial. The loss of money earnings are those occasioned by the period of disability, and the capitalized value of the future earning power cut off by death. The loss of earnings during disability is merely the money measure of the disability already considered; and the capitalized value of the unlived years of work is merely a partial money measure of the loss of life. In a sense, therefore, the computation of the total money loss, including loss of earnings and capitalized labor power, covers most of the costs already considered. THE COST OP TUBERCULOSIS, AND ITS REDUCTION.— FISHER. 17 In speaking of the great cost of tuberculosis among workingmen in pro- ducing relative inability to work, Dr. Price says: " Of 177 wage-earning males tabulated in this paper among whom care- ful inquiry was made concerning the original and ultimate economic condi- tion, 72, or 40 per cent., became dependent on charitable aid during the course of their disease; 26, or 14 per cent., died in charitable institutions; and we have good reason to suppose that the majority of others received at some time charitable aid. . . . "Histories of such families show that the result of such long-continued illness is not only a complete exhaustion of the family treasury, but an ultimate destruction of a considerable portion of the family from the disease. There seems to be no other disease of such malign influence in its tendency to bring the family unit down to the lower levels of social and material wel- fare." The figures of Dr. Price include loss of wages during the period of partial disability and during the perod of complete disability; also the expendi- tures falling on the patient, those falling on the family, the cost of mainte- nance, and expenditures incident to death. Dr. Price estimates the income for unskilled labor at $300 per annum. Among cases of great loss, Dr. Price finds one, the case of a man aged 66, who was totally disabled during three years, and suffered an actual loss during that time of $8800, and a "potential loss," that is, the cutting short of earning power by death, of $28,600. The Maryland Commission on Tuberculosis, using Dr. Price's figures, finds: "The average individual loss entailed by the disease for each wage- earning male dying from tuberculosis in Maryland is $741.64." " The average potential loss to the community entailed by the death of each wage-earning male is $8,512.52."* "The total potential loss to the State entailed by the deaths from tuber- culosis each year cannot, at the very lowest estimate, be less than ten million dollars." Dr. Huber quotes Dr. W. H. Thomas, of Chicago, who estimates that the cost of tuberculosis in the State of Illinois amounts to thirty-seven million dollars annually; and the Ohio State Commission estimates the loss in Ohio at seven million dollars annually. Concerning New York city, Dr. Biggs writes: " It may be conservatively estimated that each human life at the average age at which the tubercular deaths occur is worth to the municipality $1500. The cost of each life at this age is usually more than this. This * This estimate is high, owing to the fact that the earnings are not discounted and the consumptive is supposed to have naturally as high an expectation of life as others of his age. 18 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. gives a total value to the lives lost annually of $15,000,000. [For New York city.] "We may further assume that for an average period of at least nine months these persons are unable to work and must be cared for. The loss of their services during this period may be estimated at $1 per day, and the cost of food, nursing, medicines, attendance, etc., at $1.50 more per day, making a further loss of $2.50 a day for each person dying for a period of 270 days. This gives us a further loss to the municipality of $8,000,000, making a total annual loss to the city from tubercular diseases of at least $23,000,000. It has been estimated that in the United States annually not less than 150,000 deaths are caused by the tubercular diseases,, and estimating the value of these on the basis just given, we have an annual loss to the country of more than $330,000,000."* Dr. Huber, assuming that there were 1J millions of tuberculosis cases in the United States, and that one fourth of them cannot work, and that the wages lost are $1.50 a day, has estimated f that there is an annual loss in wages of $140,000,000. In a paper on "Economics of Tuberculosis, "J Dr. Huber quotes Cornet for Prussia, stating that for 300 working days of the year, the German consumptive, for whom he allows one year of disability before dying, loses 2 marks daily, or 600 marks in all. To this he adds 2.2 marks per day for physicians, medicines, food, and care. As 72,000 die from tuberculosis, this makes a loss of over 86 million marks annually, or 3.1 marks per capita in Prussia. Among the few curable cases who are treated and partially recover their working power, the subsequent loss of efficiency shows itself in reduced money earnings. Dr. Bardswell§ gives the following figures as loss of wages in typical cases of workmen in whom tuberculosis had been arrested: 4s., 6s., 12s. 6d., 2s., 6s. 6d., 16s. 6d., per week. In one case there was no change, and in three other cases there was a gain of 4s., 4s., and 5s. respectively, or in all an average loss of 3s. 2d., which amounted to about 13 per cent, of the wages. These figures which have been given are for the poorer classes, and there- fore should be taken to represent rather the minimum than the average cost of consumption during the life of the patient. For the well-to-do, the money expenses are enormously greater because of a longer period of refrain- ing from work, and because of the higher rate of earnings forfeited during that period, and because of the more lavish expenditure of money for medi- cal care and change of climate. In order to obtain a few typical cases of expenses occasioned by tuber- culosis among the well-to-do, I have made inquiries among physicians and * Handbook of the New York City Charity Organization Society, t "Consumption and Civilization," by Dr. John B. Huber, pp. 89-92 t New York Medical Journal, Oct. 8, 1904. § "The Consumptive Working Man," by Noel D. Bardswell, Scientific Press London, 1906, p. 65. ' THE COST OF TUBERCULOSIS, AND ITS REDUCTION. — FISHER. 19 patients in Colorado. These show that the cost of tuberculosis among the well-to-do is surprisingly great. One New York merchant, by no means reckoned wealthy according to modern standards, estimates that during the period of his illness there had been an annual lessening of his income, as compared with what it would otherwise have been, of over $21,000, as follows: ANNUAL COST OF ILLNESS. Loss of business for six months preceding illness $5,000 One year cost at Saranac $4,500 Less regular expenses 1,500 3,000 Loss occasioned by absence from business in New York 8,000 Cost of seeking new location in West 3,000 Loss in income during change 2,000 $21,000 This patient had the good fortune to have his disease arrested. He has decided to remain in Colorado, although this continues to entail upon him an annual loss which he estimates at $22,500, and which has thus far been incurred for seven successive years, as follows: ANNUAL COSTS NOW. Loss each year, at present, because of unusual absences irom busi- ness because of voluntary and enforced vacations, say $8,000 Decreased physical efficiency, say 7,000 Additional domestic expenses 2,500 Additional personal expenses 1,000 Extra traveling and vacation costs 2,500 . Doctors, medicines, nurses, etc., of family and self 1,500 $22,500 It is fair to add, however, that as this man states in his letter to me, " these figures do not take into account any of the gain which I believe to be my portion. I would not go back to the old life that I leftj with its engrossing cares, for all the financial cost. My life out here in the West has been so much more pleasant in many ways, and in addition to this my very illness gave me a love for the out-of-doors which would never have come to me in a big city like New York." Most consumptives are not so philosophical, even among the fortunate few in whom the disease is cured or arrested. In another case, which also was cured, there was a period of complete disability for 3 years, followed by a period of partial disability for 2 years, after which the patient resumed full work. The financial loss during these 5 years is estimated at $18,000, or an average of $3600 a year. Dr. Gildea, of Colorado Springs, after looking over a long list of patients and estimating as carefully as he could the financial loss which he knew them to suffer, concludes: "I have patients who have been spending from $10,000 to $20,000 a year from 5 to 15 years, with very little prospect of any end to 20 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. the expenses. Even people in moderate circumstances spend $1000 a year from 1 to 5 years before they resume even partial work." We shall now attempt to make a very rough estimate of the average cost of tuberculosis in all classes. Unfortunately there are no exact figures for earnings in the United States. For rough purposes we may use the law of distribution of earnings which Vilfredo Pareto* has found uniformly applying in numerous states of Europe and at different periods of history. To apply this law we need only know the usual minimum wage for unskilled labor. Fortunately there are enough trustworthy estimates and observa- tions of the wages of unskilled labor to make us reasonably certain that $1 a day for 300 days in a year, or $300 a year, is no exaggeration for the usual minimum. The result of the computation from Pareto's law of distribution is that the average income earned by workers of all classes in the United States is about $800, including the entire range of incomes from $300 to $30,000 or more a year. This result is not to be relied upon as a statistical fact, nor is it quite to be classed among statistical guesses. Although it is only a rough calculation, there can be little doubt, on the basis of the great uniformity which Professor Pareto finds in different countries and at different times in the distribution of incomes, that it is roughly true. In order to give a wide latitude of possible error we may say that the average probably exceeds $700 a year, and cannot be much over $1000. Hon. Carroll D. Wright, whose opinion is probably worth more than that of any other man in the United States, says in a letter to the writer, that he would not regard $1000 as excessive. Inasmuch as we are here more interested in a safe minimum than in an exact average, we shall, in the following estimates, use $700 as a basis of calculation. That this figure is safe is evident from several corroborative sources — for instance, the report of the Bureau of Laborf shows that the average income from 2116 male heads of families among the worldngmen investigated with reference to the cost of living was $648. Others of the working classes, such as women and unmarried young men, earn less than this figure, but, on the other hand, the average must be raised considerably by the far larger incomes of the higher industrial and professional classes. We assume that for worldngmen in general the periods of partial or total disability are the same as those found in Maryland by Dr. Price. As we have seen, the average for the whole community will be somewhat larger, but in order to be on the safe side — that is, to be sure that our estimate of costs is below the truth — we shall take 1$ years as the duration of the period of partial and also of the period of total disability. We may now compute that the average loss of earnings from tuberculosis for the entire country * Cours d'Economie Politique, 1897, vol. ii. t Eighteenth Annual Report, 1903, p. 97. THE COST OF TUBERCULOSIS, AND ITS REDUCTION. — FISHER. 21 must be at least $525 during the period of partial disability, and $1050 during the period of total disability, or $1575 in all. The above figures do not take into account the cost of medical atten- dance, medicines, special food, nursing, etc. It is impossible to give any but minimum figures for the expenses, but we are probably safe in taking $1.50 per day (the figure which Dr. Biggs has taken in New York city for workmen alone) or $800 for the period of total disability, without making any allowance for the period of partial disability. This will bring up the total cost preceding death to about $2400. In the same way we may estimate roughly the capital cost through the cutting off of useful life. First, reckoning that the average American con- sumptive loses 21 years of working life, and discounting at 5 per cent, the earning capacity according to the above tentative figures at $700 per year, we find the capitalized earning power thus cut off amounts to about $9100 for each death. The method of calculation is like that used by Farr and other writers on the valuation of labor power.* The figures are "gross" in the sense that they make no deduction for cost of support. Adding the $2400 of cost preceding each death to the $9100 cut off by death, we reach $11,500 as the total average cost. The above figures have been worked out on the hypothesis that the vic- tim of tuberculosis, had it not been for this disease, would have been subject to the ordinary mortality. But, making full and more than full correction for constitutional weakness, which has already been discussed, and substi- tuting for the 21 years above ascribed to the working period of life the cor- rected figure of 17 years, we get $7000 as the discounted value of the earn- ing power cut off by each death from tuberculosis. This, added to the $2400 of cost preceding death, gives $10,300 as our minimum estimate of the total money cost. We must reduce this estimate, however, still further, owing to the fact that not all persons of working age are actually bread-winners. The census figures show that over 90 per cent, of men over 16 years of age and 20 per cent, of women are employed in gainful occupations. Two-thirds of the women are single. The estimate for women does not include married women who do their own [housework as among those engaged in " gainful occupa- tions." However, although not earning money, housewives perform work which is worth money, and their death causes an actual money loss to the family. When the housewife dies, a hired housekeeper or servant must be employed, or else the family must go to the expense of boarding out; in any case, it is fair to regard the death of an active housewife as a money loss. * For an interesting general application of the method to include the calculation of indemnity for lost earning power through maiming, disability, or death, see "Physical Economics," by E. E. Holt, Journal of the American Medical Association, July 21, 1906. 22 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. If we take this fact into consideration, it will be found that two-thirds or more of women at working age are actually at work. This ratio, taken in connection with the corresponding ratio for men, shows that over three- fourths of all persons of both sexes of working age are either actually earning money or saving expense by housekeeping. Using this ratio of three- fourths, which is a safe minimum, as expressing the ratio of actual workers to those of working age, and spreading the cost of $10,300 for the actual workers over all those of working age, including those who do not work, we find that the average death from tuberculosis means an actual money loss of $7725; and, remembering that the cost of medicine, nursing, medical attendance, etc., is just as great in the cases of non-workers as in the case of workers, we may say that the average cost is at least $8000, of which $2400 occurs in illness preceding death and $5600 from death itself. This $8000 must, however, be still further reduced if we wish to compute the loss suffered by the community as distinct from the loss suffered by the consumptive himself. The earnings are, to a large extent, merely a loss to the dying consumptive himself. These evidently stand on a different foot- ing from the expenses which have to be borne by others. These latter costs we wish now to segregate. Including housewives, we find that the workers constitute about 45 per cent, of the whole population. The other 55 per cent, are dependent upon them. The ratio, however, in which the incomes of the 45 per cent, are consumed by themselves and the remaining 55 per cent, of the population will be more than 45 to 55, owing to the fact that the 55 per cent, include children. If we take the rough estimates of consuming power of the Bureau of Labor* and apply these to the age dis- tribution of population as given by the census, we shall find that those who constitute the 45 per cent, of population which works consume about three- fifths of the total product, leaving two-fifths to be consumed by the remain- ing 55 per cent. We may, therefore, conclude that approximately two- fifths of the money loss entailed by the death of consumptives falls on others dependent upon them. Applying this figure, we find the cost of $8000 entailed by each death from consumption, $4800 is loss to the con- sumptive himself and $3200 to others, as, for instance, his wife and the children which he has and would have had. This sum, $3200, may be con- ceived as practically the insurable interest which the family or friends of the consumptive have in his fife— a sum such that his life should have been insured by that amount in order to indemnify others for the economic loss occasioned by his death. Since we have found that there are annually over 138,000 deaths from tuberculosis in the United States, the annual loss occasioned to others than the consumptives themselves exceeds $440,000,000, and the annual loss to consumptives themselves exceeds $660,000,000, * Eighteenth Annual Report, 1903, p. 19. THE COST OF TUBERCULOSIS, AND ITS REDUCTION. — FISHER. 23 making a total annual loss of about $1,100,000,000. If this annual loss should continue indefinitely, it would represent capitalized an offset against or deduction from our national resources of $22,000,000,000. These figures are the minimum measure of that part of the cost of tuberculosis which can be expressed in money. If we apply these figures to the deaths which may be expected from the total population now living, which has already been calculated at 5,000,000 persons, we find that, at $8000 per head, the total cost occasioned by the illness and death of people now living will eventually be over $4,000,000,000. Another method of dividing the money cost for each death is to distin- guish between gross and net cost. Dr. Farr has computed the gross and net value of a laboring man from birth up to old age. The gross value is the capitalized value of future earnings; the net value is the gross value less the capitalized value of the cost of maintenance. The following figures for representative ages illustrate Dr. Farr's calculations:* Agb Vattti. Cost of Vnm? VALUE. M AINTEHANCE. VALUE. 148 143 5 30 474 233 241 60 238 141 97 If we take the ratio of capitalized cost to gross value, we find that it is remarkably constant during the ages at which consumptives die. This ratio at the ages 20, 30, 40, and 50 is respectively 51, 49, 50, and 51 per cent. Assuming, for want of better data, that these ratios apply for American workers of all grades, we find that the weighted average ratio of net to gross value, on the basis of the deaths from tuberculosis at different ages, is ap- proximately 50 per cent, for each worker who dies from tuberculosis. Since we have already shown that the gross value for each worker dying from tuberculosis is at least $7900, we may assume that the net value is 50 per cent, of this, or about $4000, and that the difference, $4000 also, is the capi- talized cost of maintenance. Since we have estimated that only about three-fourths of those who die from tuberculosis are actual workers, we must spread the $7900 capitalized earnings per capita for workers over all deaths, making $6000 per capita and subtract from this the $4000 capitalized cost of maintenance, which applies to all the deaths, whether of workers or non- workers. This leaves $2000 as the net capitalized cost of earning power cut off by death. This is the cost of death. As to the cost of illness preceding death, the lost earnings are all net. That is, before death tuberculosis costs the victim lost earnings and does not save him or any one else the cost of support. These lost earnings, we have seen, amount to about $1600 per worker, which means $1200 per death, which, added to the $800 expenses of * "Vital Statistics," London, 1855, p. 536. 24 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. sickness, makes $2000 of total costs preceding death. Adding this $2000 to the preceding $2000, we find $4000 as the minimum estimate for the total net cost per death from tuberculosis. Multiplying this figure by the mini- mum estimate, 138,000 deaths annually in the United States, we obtain $550,000 as the annual net cost of tuberculosis in the United States, or half the gross cost of $1,100,000,000. In computations in which the data are so meager, especial pains have been taken to understate the cost of tuberculosis. The figures, where they cannot be exactly ascertained, are all minimum figures. The truth must, there- fore, be greater than the estimates given, probably by 25 per cent., possibly by 100 per cent. Moreover, it must be remembered that the computations have not included the unknown losses from latent tuberculosis. As has already been remarked, it may well be that in the aggregate these losses equal or exceed those from the disabilities in "active tuberculosis" which precede death. Nor have we attempted to evaluate the loss in happiness, or "men- tal anguish." While it is impossible to compute in dollars and cents "mental anguish" and other "sentimental" values of life, it must not be forgotten that these values exist, and are even more precious than cold earning power, an esti- mate, or rather a minimum estimate of which, can be made. In reckoning the "net" value of lives lost from tuberculosis, we assumed that the non- worker is worse than worthless, for he costs money in support and con- tributes no earnings. His capitalized value, therefore, entered our calcula- tions as negative or subtractive terms. In other words, the calculation of net value treats the whole leisure class as though they were economic para- sites, and counts a man's wife and children, so long as they are not engaged in "gainful occupations," as merely items of cost, but yielding nothing in return. If this were true, it would profit each worker to get rid of all his dependents, and he should feel economically benefited when tuberculosis destroys his wife or children. Obviously such a view is not only partial but absurd. It is true that the death of a dependent saves money to the sup- porter, but a full economic view should include how much sentimental value the head of the family puts on his dependents. It would be only where little or no such sentimental value exists, as, for instance, in the case of the paupers, criminals, and defective classes, in penal institutions, reforma- tories, poor-houses, etc., where it would be even approximately correct to say that deaths from tuberculosis constitute an economic saving to society. The number of deaths among such classes which are chiefly a burden is extremely small. The man who spends a great deal on his family does so because they are so precious to him, and this expenditure, while a cost, is mostly significant as indicating that he conceives a sentimental value which is high, though impossible to express in figures. In practically estimating THE COST OF TUBERCULOSIS, AND ITS REDUCTION. — FISHER. 25 the actual economic losses from tuberculosis it would be therefore probably more correct to adhere to the so-called "gross" cost; in other words, to assume that each person, even a non-worker, is "worth his salt" to some- body. IV. Reducing the Cost. If only one-fourth, or 1,250,000, of the 5,000,000 lives to be lost from among the present generation alone can be saved, the effort of saving them will be worth a billion dollars. That this result can be achieved, and at much less cost, no one who has studied the subject can be in doubt. Or again, let us consider, as a practical business enterprise, what it would be worth to a nation to permanently reduce by one-fourth the annual cost of tuberculosis. This would mean an annual saving of over $275,000,000, the capitalized value of which would be $5,500,000,000. If it should require the investment of this amount to secure the saving of one-fourth of the annual deaths from tuberculosis to present and successive generations, the investment, from a purely monetary point of view, would be paying 5 per cent. If, as is unquestionably the case, the result be secured with a much smaller expenditure, the returns would be proportionately greater. At present the sum annually invested in the attempt to cure tuberculosis, in spite of its large absolute amount, sinks into insignificance when consid- ered in comparison with the waste of life which it is intended to combat. Dr. Biggs estimates that the total expenditure in the city of New York in ^ts public institutions for the cure and treatment of tuberculous patients is not over $500,000 a year, which is about .5 per cent, of the economic waste from tuberculosis in New York city alone. The question is sometimes asked whether or not it pays to try to save the lives of consumptives. Dr. Bardswell, in his book on the "Consumptive Working Man," answers this question with an emphatic "yes." Even a cursory examination of the facts will make it clear that he is right. Taking one of the typical American sanatoriums in which excellent treatment is given at a greater expense than in some of the smaller institutions, it is found that the average cost of treating a patient during the average stay (three months) is $175. This takes into consideration the interest on the capital invested and depreciation. The prolongation of life by the sanatorium treatment has been already shown. About one-third of the patients are discharged with active tuberculosis, and their lives continue on the average about four years. Another one-third have the disease arrested, and live on the average ten years after leaving the sanatorium. The remaining one-third are ap- parently cured, and their average prolongation of life is not certain, but is more than 16 years. The average prolongation of life, for all classes, is, therefore, more than 10 years, which must certainly effect a saving of several thousand dollars, both to the patients and to those dependent upon them. 26 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. The major part of this saving can properly be credited to the sanatorium treatment, and repays manifold the investment of $175. These calculations do not take into account the indirect benefits from the sanatorium treatment. All students of sanatoriums are agreed that the principal benefit is indirect, through the influence which discharged patients have on the habits of living in their family and neighborhood. It is im- possible, however, to express these benefits in figures. The object of our movement is, however, not so much the cure of those who fall into the grasp of our microscopical foes as to prevent the disease from spreading. Only in this way can it ever become eradicated. Our hope and belief in the practical eradicability of tuberculosis is based not on theory only, but on facts. These facts are of two kinds: one is the wide variations in tuberculosis in different conditions; the other, the great re- ductions which have already been made in the death-rate from tuberculosis. The figures for death-rates which we have already given show a remarkable variation. The new countries, like Australia, lead in freedom from the disease. In New Zealand the death-rate is especially low, being 57 per 10Q,000 in 1905, in spite of an age distribution favorable to the disease. The death-rates in Austria and Servia are nearly six times as great. There is also great variation in the death-rates in the various States of the United States. Thus, Michigan has a death-rate as low as 90 per 100,000, while Maryland has 18^ per 100,000.* Individual citites show great differences in death-rates. In Scranton, Pa., the death-rate is 72, and in St. Joseph, Mo., the death-rate is 86. These are extremely low. At the other end of the scale we find the death-rate in the city of Washington,! 254; San Francisco, 276, and in the Bronx Borough, 503! There is no way of explaining these great differences in the life-cost of tuberculosis in various countries except by differences in environment. Other differences, such as those of race, sex, or age, distribution of the various populations, or differences in the accuracy of statistics, are quite insufficient to account for the facts. The influence of these factors and others has been investigated sufficiently to make it practically certain that en- vironment is the supremely important cause. J * If we take States which are resorts for consumptives, we find the death-rate much higher, that for Colorado being 253 per 100,000. t The city of Washington has a death-rate from the whites of 159 and from the colored of 463 (Census, "Mortality Statistics, 1906," p. 52). I Aside from environment, the only important cause to which the variations in tubercular mortality might be ascribed are age and racial susceptibility. Age has already been discussed and accounted for. Part, if not most, of the so-called racial differences in respect to tuberculosis are at bottom not racial at all, but environmental. The Negroes and Irish, for instance, have high tuberculosis death-rates, in part because of bad housing and bad economic conditions. As to the high death-rate among THE COST OF TUBERCULOSIS, AND ITS REDUCTION. — FISHER. 27 The chief environmental factors^affeGtia&ihe^death-rate from tubercu- losis are of two kinds: (1) Exposure to tubercular lnf^onTl^ , ~an a-tnF hygenjfi_conditionj of ^Jiving which lower the_physiological resistance to infection. We need not, in this paper, enter into particulars, except to TpamTouTthat poverty is one of the causes of tuberculosis, as well as one of its effects. What is often mistaken for the influence of race is the influence of occupation or economic condition. That poverty, which always means bax^hoJtisiHgr^assQciated with tuberculosis is well known. Bulstrode has given the death-rate from pulmonary tuberculosis in Hamburg according to income tax classes. That for incomes of 900 to 1200 marks is 55.4; that for incomes of 25,000 to 50,000 marks is 7.5, or one-eighth as much. Similar statistics have been given by other writers, such as Reincke, Biggs, Hoffman, Brandt, Korosi, and others. As Casimir-Perier* has said: " The struggle with tuberculosis is intimately bound up with the solution of the most complex economic problems, and no plans will be complete which have not for their basis the material and moral improvement of the people. The struggle with tuberculosis demands the mobilization of all social forces, public and private, official and voluntary." Not only will the reduction of tuberculosis lessen poverty, but the reduction ofjDQxerty jadlHessen -tuberculosis. In this connection it should not be forgotten that the poor, among whom most of the infection occurs, change dwellings frequently, and thus rapidly spread iiifjJction^greatJn-aay'Gase; — — WeTcannot here repeat or elaborate statistics showing the reduction in the death-rate from tuberculosis already achieved. A few illustrations may, how- ever, be given as an introduction to the economic aspect of this subject. Dr. Biggs estimates that for the boroughs of Manhattan and the Bronx in twenty years there has been an actual decrease in the total number of deaths, notwithstanding an increase in population of nearly 70 per cent. The late Dr. S. W. Abbott, formerly secretary of the Massachusetts State Board of Health, f shows that the death-rates in Massachusetts from con- sumption of the lungs per 100,000 have declined as follows: the Irish, see Dr. Newsholme, on "Phthisis Death-rate," Jour. Hygiene, July 1906, The death-rate from tuberculosis among the Negroes and Indians is also raised by the prevalence of syphilis and alcoholism, which create a predisposition to tuberculosis. The Jews have a low death-rate, but in an article on "Tuberculosis m the Jewish District of Chicago" (Journal of the American Medical Association, Aug. 6, 190*)-Dr._ TheodDW-B-rS'acEs"proves thatluBeTCHiesis amottg-the- J«waJs.jeaHy-grearter-than the figaresshow, because when the Jews fall sick, they almost invariably seek a different Washington Government Printing Office, 1908), as well as to their out-of-door habits. * "Consumption and Civilization," by Dr. John B. Huber, p. 326. t Quarterly Publication of the American Statistical Association, March, 1904, "The Decrease of Consumption in New England." 28 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. Deaths peb Yeaes. 100,000. 1851 to 1860 399 1861 to 1870 349 1871 to 1880 327 1881 to 1890 292 1891 to 1900 214 1906 156* Dr. Abbott shows, in the report on consumption in New England pre- viously referred to, that the annual decrease of tuberculosis in percentages in various States of New England was, at the time of writing, as follows: Maine 3.8 New Hampshire 2.2 Vermont 3.1 Massachusetts 2.8 Rhode Island 1.7 Connecticut 1.9 In the United States as a whole, judging from the census figures, the death-rate from tuberculosis is now probably about three-fourths of what it was twenty years ago. In Prussia the death-rate from tuberculosis between 1875 and 1887 oscillated between 310 and 325 per 100,000, and then descended! with great regularity to about 180 to-day. Englaad has the distinction of having the lowest death-rate from con- sumption of any large country in Europe, and the decrease in the death- rate from tuberculosis, since the statistics of the disease have been kept, have been very marked. In England in three-fourths of a century the death- rate from tuberculosis has fallen to one-third of what it was. Mr. Hayward, the medical officer of health for Haydock, Lancashire, England, who has already been quoted, shows the extent to which, on the basis of the decennium 1891-1900, life had been lengthened through the reduction of deaths from phthisis, as compared with the decennium 1881- 1890. He compares the mortality in 1891-1900 with what that mortality would have been if the death-rates from phthisis had been the same as they were in the previous decennium, 1881-1890, and if phthisis had prevailed as a cause of mortality with the same proportionate intensity. In this way he measures the proportionate number of lives actually saved during 1891-1900 by the reduction in mortality from phthisis, as compared with 1881-1890. He finds that through the reduction in tuberculosis alone within ten years the male expectation of life of the general population had lengthened by 0.45 year, and the females, 0.68 year. J * This figure is taken from Census Report, "Mortality Statistics, 1906," p. 51. t See Zeitschrift fur Tuberkulose und Heilstattenwesen, April, 1903. J See also "The Mortality from Phthisis and from other Tubercular Diseases," by the same author, in the Transactions of the British Congress on Tuberculosis, London (Wm. Clowes), 1902. THE COST OF TUBERCULOSIS, AND ITS REDUCTION. — FISHER. 29 Bulstrode* has emphasized the almost universal tendency of tubercu- losis to decline. Many quoting his figure have concluded that the tendency is due to some mysterious reduction in the virulence of the disease. One can scarcely doubt, after reading what Newsholme has written, and in view of the universal improvement in sanitation, that the reduction in the disease is no mystery, but is a natural and necessary consequence of the efforts being made to combat tuberculosis and disease in general, f The means by which the devastation of life and property caused by tuberculosis may be further reduced are well known: a more prompt diagno- sis of tuberculosis; the exactments and enforcement of laws securing the reporting of tuberculosis eases; the prohibition of indiscriminate expectora- tion; the disinfection of premises occupied by infectious cases; free examina- tion of sputum; the prevention of overcrowding; the destruction and pro- hibition of windowless sleeping-rooms; the better sanitation of places for work, schools, public buildings, and private dwellings; cleanliness in streets; purer foods, especially meat, milk, and butter; the establishment of sana- toriums, isolation hospitals, dispensaries, the education of the physician, and — last but not least — the education of the general public through tuber- culosis classes and the dissemination of information as to how to live hygienically — the establishment, in fact, of higher health ideals. Besides other agencies for the achievement of these results, there should be a national health organization, formed by combining into one department the existing scattered health agencies of our Federal Government, and adding new bureaus, especially one of information on matters of health. In the opinion of the writer, the best immediate results are to be obtained by the isolation of the incurable consumptive — a field of investment even more fruitful than sanatoriums. It is true that no immediate economic benefit to the patient or his family accrues from such hospitals, and this fact has hitherto led to the more generous endowment of sanatoriums for curable cases; but a broad view must recognize the fact that isolation hospitals, by preventing the spread of infection and gradually reducing the mortality from tuberculosis, indirectly repay to society a very handsome profit on the investment. Dr. NewsholmeJ has explained more satisfactorily than any one else the decrease in the death-rate from tuberculosis which has been going on even * Thirty-fifth Annual Report of the Local Government Board, 1905-06, Sanatoria for Consumption, London (Darling), 1908. t To some extent the reduction in tuberculosis is apparent rather than real, due to the fact that formerly any wasting disease was sometimes set down as consumption, and the fact that to-day, on the other hand, some deaths actually due to tuberculosis are concealed, being set down to pneumonia, bronchitis, etc.— m order, especially, to secure insurance, which otherwise would be invalidated. The extent of this vitiation of comparative statistics can only be guessed at, but is not usually believed to be great. t "Phthisic Death-rate," Journal of Hygiene, July, 1906, pp. 304-384. 30 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. prior to the discovery of Koch, and prior to the attempt to establish special hospitals or sanatoriums for its treatment. He points out that this steady reduction has occurred in almost exact proportion to the use of public hospi- tals, which have taken the consumptive away from his home and thereby reduced the amount of infection which he communicates to his family and neighbors. We all know or believe we know that to a great extent the foci of infection perpetuate themselves, especially in tenement districts. It is, therefore, somewhat surprising that the explanation of Newsholme has not been em- phasized earlier. Newsholme has shown that the reduction of tuberculosis in England has not been due to the erection of special hospitals for con- sumption. Such special hospitals have been altogether too few and too recent to have caused so great and prolonged an improvement. He has also shown that the death-rate from tuberculosis has decreased in different countries in proportion to the extent to which "in relief" in public institu- tions has replaced ''out relief" in the homes of the sick, and that the apparently anomalous increase of consumption in Ireland is explainable through the relative increase in the ratio of "out relief" as compared with "in relief" in that country.* Without relaxing any of our other efforts to conquer tuberculosis, we ought to make, on a large scale and immediately, provision for isolating in- curables. This will, of course, cost money, but the fight against tubercu- losis is bound to be costly, and consists in fact of substituting money cost invested in hospitals, attendants, and education for the far greater cost now incurred from death and invalidism. We have already seen that money invested in the effort to eradicate tuberculosis would be money well invested. It has been claimed that a practical demonstration of this has already been made in Germany; that, in fact, the money invested in sanatoriums for workingmen, in connection with the governmental system of workingmen's insurance, has been repaid to the insurance companies. It has therefore been suggested that it would pay insurance companies to establish sanatoriums for the treatment of tuberculosis. While it richly repays the community to establish such sana- toriums, it is extremely doubtful if it is true that insurance companies would be financially bettered by embarking on such an enterprise. Mr. Hoffman has shown that the contrary would more likely be the case.f Mr. Hoffman says: "As a financial proposition, I am confident that the German system of sanatoria for consumptive workmen can never be made to rest upon sound * See also Ireland's "Crusade Against Tuberculosis" (2 vols.), Dublin (Maunsel), 1908, vol. i, p. 71. t "Industrial Insurance and Tuberculosis," by Frederick L. Hoffman, Medical Examiner and Practitioner, Dec, 1901. THE COST OF TUBERCULOSIS, AND ITS REDUCTION.— FISHER. 31 actuarial principles and be made a paying proposition."* He points out that the cost per patient of the industrial population, treated in a sanatorium, could scarcely be less than $100 or $120, which would be several times as much as any possible returns, so small is the premium in industrial com- panies. Neverthleless, he shows that there has been a great loss to the Pru- dential Life Insurance Company from consumption, the annual cost to that company being about $800,000. Selecting the figures for the consumptives, he finds that, on the average, they have paid $24 and have cost the company $134. Among the early ages, the loss is still more striking. For ages 25 to 29, the company receives $18 per capita in premiums and pays out $150 in losses. The reason for the great losses suffered from tuberculosis among insurance companies is due to the fact, as Mr. Hoffman points out, quoting the words of Dr. Green, author of the most recent treatise on medical examination in life insurance, as follows: "Curiously enough, despite the well-known infectivity of tuberculosis, insurance companies have, until quite recently, failed to inquire as to the applicant's association with consumptives. As a result of this omission, companies have insured thousands of men exposed daily in their own house- holds to infection through their wivesf or children." German insurance has, however, entirely justified itself on the ground of general public policy. It may be said with considerable confidence that the benefits already received by society exceed many times the efforts which have been put forward to achieve them. Dr. Arnold C. Klebs thinks that the system of insurance for workingmen in Germany has become "the most powerful factor in the tuberculosis pre- vention in that country," J and adds, "The tremendous expenditure neces- sary for this has been amply justified by the results."? Dr. Ulrich, || in "Tuberkulose und Arbeitsversicherung," quotes from Bielefeldt (Ztschr. f. Tuberk. u. Hlsttw., Bd. vi, Hft. 3, S. 201): " Over 29,000,000 marks have been spent up to 1903 for sanatoria, and 27,000,000 marks for the care of consumptives in these institutions; 78,329 * Transactions of the Second Annual Meeting of the National Association for the Study and Prevention of Tuberculosis, p. 155. t The most complete study of marital infection is that of the late E. G. Pope, of Saranac Lake, edited by Karl Pearson, Drapers Co. Research Memoirs, London, Oulan, t Transactions of the Second Annual Meeting of the National Association for the Study and Prevention of Tuberculosis, p. 144. . § Ibid., 145. Also, Dr. S. A. Knopf, "What shall we do with the Consumptive Poor?" Medical Record, July 5, 1902. . || "A Preliminary Discussion of Workingmen's Insurance Against luberculosis, by Dr. Henry L. Ulrich, St. Paul Medical Journal, 1905. 32 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. consumptives have had care for a period of seventy-two to eighty-seven days. Besides this, all large centers are provided with daily excursion spots sit- uated somewhere in the neighboring country, and some of the societies own convalescent homes. From the report of twenty of the states of Germany, the decline of the mortality from tuberculosis in 1900-01 was 4.4 per cent.; in 1901-02 was 1 per cent." While, therefore, it may be difficult to contrive a scheme by which in- surance companies can make money by curing tuberculosis, it might pay them handsomely to expend money in educating their "risks." Moreover, there can be little doubt that, in a broader view, the community can " make money" even by curing tuberculosis. If the facts were possible of tabula- tion, it would be found that the money already invested by society in this fight had been returned many times over. Dr. H. B. Baker, in the "Teachers' Sanitary Bulletin of Michigan" for April, 1905, issued by the State Board of ;Health, shows a saving of 583 lives per annum from tuberculosis during 1898-1903, as compared with a previous period of 1869-91. Computing each life as worth $1000, he reckons that this makes an annual saving of double the cost to the State. We most note, finally, that the problem of tuberculosis is only one small part of the whole problem of public health. There are other diseases equally preventable and almost as costly, particularly insanity. Fortunately to a large extent the same efforts put forth to reduce tuberculosis will, at the same time, reduce largely other diseases, for the method of preventing and curing tuberculosis is at the bottom merely the promotion of hygienic habits and conditions of life. Pasteur has said that it is within the power of man to rid himself of every parasitic disease. It is, however, no part of the present paper to study the more general aspect of the economics of disease. Many interesting articles have already been written on the subject.* VI. Summary. The chief results of this paper may be briefly summarized as follows: The cost of tuberculosis is fourfold — cost in lives, cost in disability, cost in happiness, and cost in money. The death-rates from tuberculosis per 100,000 of population in the United States in 1906 were as follows: * Among the strongest statements of the economic waste from disease are the three papers, one by Professor J. P. Norton, on "The Economic Advisability of In- augurating a National Department of Health" (Journal of the American Medical Association, Sept. 29, 1906); another by Professor Norman E. Ditman, on "Education and its Economic Value in the Field of Preventive Medicine" (Columbia University Quarterly, June, 1908); and a third by Dr. George M. Kober, on "The Conservation of Life and Health by Improved Water Supply" (Publications of the Conference on Natural Resources, held at the White House, May, 1908). THE COST OF TUBERCULOSIS, AND ITS REDUCTION. — FISHER. 33 Registration Continental U. S. Area. (Estimated). Tuberculosis of the lungs 159 142 Tuberculosis of all kinds \\ 184 164 The number of deaths in 1906 in the United States from tuberculosis were: Registration Continental U. S. Area. (Estimated). Tuberculosis of the lungs 65,341 119,000 Tuberculosis of all kinds 75,512 138,000 The total number of deaths from tuberculosis is equivalent to the total number of deaths from smallpox, typhoid fever, scarlet fever, diphtheria, cancer, diabetes, appendicitis, and meningitis. The total number of persons constantly suffering from active tuberculosis in the United States is about 500,000. There are always one to two million people in the United States being rendered miserable through illness from tuberculosis in the family circle, and as many more mourning the loss of friends. Of those now living in the United States, the number who will die of tuberculosis, if the present rate of mortality continues, is about 5,000,000. Tuberculosis of all kinds causes one in every nine deaths; tuberculosis of the lungs, one in ten. The percentage of deaths from tuberculosis of the lungs is greatest in the working periods of life, the maximum percentage being between the ages of 20 and 30, when one-third of all deaths are from this cause. The incidence of tuberculosis of the lungs is earlier for females than for males. The average age at death is for males 37.6 years; for females, 33.4 years. If we assume tuberculosis absent and that those who now die of it would conform to the ordinary mortality, we find that each death from tuberculosis cuts life short on the average 29.4 years for males and 34.5 for females^Jf" 32 years for all persons. Of this loss, the major part occurs in the working period of life, which is conservatively assumed to be the period between the ages of 17£ and 60. Males lose of this working period an average of 19.3 years; females, 23.4 years; and both sexes combined, 21.4 years. ^ But, in order to be sure of understating the costs, it is assumed that con- sumptives are usually weaker than most persons of equal age, and making a liberal allowance for this weakness, based on the mortality among those dis- charged from the Adirondack Cottage Sanitarium, we find that death from tuberculosis cuts off at least 24 years, of which at least 17 are in the working period above mentioned. On the average, each death from tuberculosis is preceded by a period of total disability, which (in turn) is preceded by a period of partial disability. VOL. Ill — 2. 34 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. For workingmen the period of total disability is, according to Price, 1 year and 6 months, and of partial disability 1 year and 7 months. For other classes the periods are probably greater. Latent tuberculosis is responsible for many protracted "colds," "bron- chitis," etc., aggregating a total disability of large dimension. The losses of money due to tuberculosis are of two kinds: (1 those preced- ing and including time of death, and consisting of loss of earnings, cost of medical attendance, medicines, nursing, special food, traveling, and funeral expenses; and (2) consisting of the capitalized value of the earnings cut off by death. The average of the former cost, up to the time of death, exceeds $2400 per death; the latter exceeds $9100, if we assume that full expecta- tion of life applies to the consumptive; or, if we make liberal allowance for constitutional weakness, it still exceeds $7900. On the latter hypothesis, the total expense corresponding to each death from a consumptive worker is over $10,300. Since only about three-fourths of those living in the working period are actual workers, this minimum is reduced to about $8000. Eight thousand dollars is, therefore, the very least at which we can reckon the average cost in actual money of a death from tuberculosis in the United States. Consequently, the total loss in the United States from the 138,000 deaths exceeds $1,100,000,000 per annum. Should this annual cost con- tinue indefinitely, it means a total capitalized loss of $22,000,000,000. The saving of one-fourth of all deaths from tuberculosis in perpetuity is worth a capital expenditure of over $5,500,000,000. Of this cost about two-fifths, or over $3200 for each death, is borne by others than the consumptive, and amounts to over $440,000,000 per annum. The 5,000,000 people, who will some time die of tuberculosis, will ulti- mately cost the world $4,000,000,000. If one-fourth of these lives can be saved, the effort is worth over $1,000,000,000. The figure $1,100,000,000 for total cost is "gross" cost. We may com- pute the "net" cost by subtracting the capitalized cost of support. This ignores any sentimental worth of life, and counts the leisure class and all dependents, such as non-working wives and children, as expensive drones instead of precious to their supporters. On this basis tuberculosis, whenever it kills a dependent, saves money for the community. Even on this narrow reckoning the cost of tuberculosis exceeds an average of $4000 per death ($2000 for the illness and $2000 for the death itself), or $550,000,000 for the nation. That tuberculosis may be practically eradicated is evidenced by the fact that the mortality varies] so greatly in different communities, and is declin- ing in almost all. The cost of treating patients at consumptive sanatoriums for incipient cases is repaid many times over, both to the consumptive himself and to THE COST OF TUBERCULOSIS, AND ITS REDUCTION. — FISHER. 35 those dependent upon him, to say nothing of the indirect benefits in lessening the disease through the education of the public. From an economic point of view, the investment in isolation hospitals for incurables is at present probably the most profitable method of spending money for reducing the costs of tuberculosis. RC 313.A2F53" UnirerS " yLlbrary i™i?i« t ™,?I,J,i ,berculosis in M»e United 3 1924 012 470 567